cause of death essay

Causes of death globally: what do people die from?

To make progress towards a healthier world we need to have a good understanding of what health problems we face today..

This post discusses data for 2019, the year before the pandemic started. Once global data for the period during the pandemic becomes available via the IHME, you can find it in our entry on the causes of death .

To make progress towards a healthier world we need to have a good understanding of what health problems we face today. What do people die from?

This visualization gives us the answer. This type of visualization is called a ‘tree map’. The size of the entire visualization represents the total number of deaths in 2019: that’s 55 million deaths. Each rectangle within it represents one cause of death: its size is proportional to the share of deaths from that particular cause. For example, 18% of global deaths in 2019 were from cancers; the rectangle representing cancers therefore corresponds to 18% of the total area. This way we can quickly see which causes kill many people, and which kill few.

The chart does not show the current situation. It shows the data for the year before the pandemic. During the pandemic the number and causes of deaths have changed. For 2020 it is estimated that 5.7 million people died from COVID and the current 2021 death toll – before the year is even over – is estimated to be 11.5 million. 1 Other causes of death declined during the pandemic. We would expect, for example, that traffic deaths would decline when restrictions were in place and travel was reduced.

What the pre-pandemic data does provide is a perspective for where global health could get back to once the pandemic retreats.

In everyday language we sometimes say that a person died of ‘old age’ or that they ‘died of natural causes’. But there is always an underlying cause that stopped their body from functioning. It is these specific causes that are visualized in this chart. When the cause of death is not recorded then researchers rely on models to estimate the cause.

Epidemiologists group the causes of deaths into three large categories:

• Shown in blue on the left are non-communicable diseases ; diseases which cannot be passed from person to person. The two most common causes of death fall into this group: cancers kill 18% of people and cardiovascular diseases – such as stroke and ischemic heart disease – are responsible for one-in-three deaths in the world.
• Shown in red are communicable or infectious diseases ; diseases that are caused by a pathogen which can be passed from person to person.
• In green you see injuries . This is a very wide category which includes accidents – such as car crashes and falls from stairs or ladders – as well as intentional injuries like homicides, war deaths, and suicides.

What the world dies from is not what is reflected in the media. Some major causes of deaths receive very little attention. Very rare tragedies draw outsized attention – have a look at the bracket in the bottom right, there you see the small rectangle that refers to the deaths due to terrorism.

Violence is, fortunately, a relatively rare cause of death. While it receives a lot of media attention, more people die from diarrheal disease than from all forms of violence put together. 2

This is the perspective we need if we want to contribute to progress against the world’s largest problems. We need a good sense of the relative importance of different causes of death and we need to focus our efforts on the biggest rectangles in this visualization. If we don’t look at the data it is easy to miss that preventing deaths from diarrhea would save more lives than bringing an end to all violence. The former should be much easier to achieve, too. We already know how to do it.

This is the estimate of the total death count from COVID according to the model produced by The Economist – which is very transparently documented by the team that produces it. This estimate is more than twice as high as the number of confirmed deaths which did not reach 2 million in 2020.

1.238 million people died from ‘intentional injuries’ in 2019:

760,000 Suicides

415,000 Homicides

63,000 Conflict and terrorism

Diarrheal diseases: 1.53 million

See our entry on diarrheal deaths .

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• v.117(4); Jul-Aug 2020

Youth Suicide: A Population Crying for Help? A System Overloaded? Who Can Help?

Suicide is the second leading cause of death in young adults (15–24 years old). There continues to be limited access to mental health services for many patients who are in mental health crisis because of shortage of trained psychiatrist and mental health providers. Patients identified with high risk factors should get a full comprehensive psychiatric evaluation. Management should focus on preventative strategies, early identification as well as treatment with appropriate psychopharmacology and psychotherapy.

Introduction

Suicide has been one of the leading causes of death in youth. It was identified as the second leading cause of death in young adults (15–24 years old) from 2011–2015. 1 According to the National Vital Statistics Reports, suicide was the second leading cause of death in younger age group of 10–24 years of age accounting for 16.8% of deaths. It was also the fourth leading cause of death for ages 25–44 accounting for 11.2% of deaths. 2 It is interesting to note, that even though suicide was among the top 10 leading causes of death in 45–64 age group it had dropped to the eighth leading cause of death. 2 In looking at the data it is clear that youth is clearly an extremely vulnerable population for suicide. What is even more alarming is there continues to be a concern for a national shortage of child and adolescent psychiatrists. This shortage led the American Academy of Child and Adolescent Psychiatry to start a work force initiative in 2002 to address this. The American Medical Association estimated 8,000 child and adolescent psychiatrists in the United States in 2013. 3 The U.S. Bureau of Health Professions estimated a need for approximately 12,600 by 2020 to meet the mental health needs of the country. 4

According to American Foundation for Suicide Prevention suicide is the tenth leading cause of death in Missouri ranking it eighteenth compared to the other states. In breaking down the suicide by age groups it is the second leading cause of death of 15–24 years, third leading cause of death of 25–34 years, fourth leading cause of death of 35–54 years, eighth leading cause of death of 55–74 years, and seventeenth leading cause of death in individuals above the age of 65. According to this report “on average one person dies by suicide every eight hours in the state.” A brief report in April 2015 by Missouri Suicide Prevention Project, the suicide rates in Missouri have remained stable but, have been higher than the national average. Seventy-five percent in 2013 were white males between the ages of 18–24 with 49% using firearms. 5

Many mental health problems in adults have origins in adolescence who lack access to services during this time. 6 Three national surveys showed that of the children between the ages of 6–17 who were screened for mental health services only one-fifth actually received the services. 7 , 8 It is also interesting to note that one-third of individuals 16 years or older presented to emergency departments in the preceding year of completing the suicide. 9

Risk Factors

The assessment of suicide risk factors should include a comprehensive psychiatric evaluation of the youth including collateral information from parents, other family members, teachers, caregivers and friends. Psychopathology, 10 substance misuse, 11 and a history of suicide attempt 12 are considered strongest predictors of future suicidal behaviors in youth. Major depressive disorder carries the greatest risk for suicide attempts and a higher severity of depressive symptoms is associated with a greater likelihood of attempting suicide. 10 , 11 In numerous studies, a history of previous suicide attempt has been associated with increased future suicide attempts. 13 – 15 A family history of suicide attempt seems to convey a greater risk of suicide attempts in youth as shown by monozygotic twin studies. 16

A history of interpersonal violence or maltreatment (e.g. being a victim of bullying or physical/sexual abuse) increases the risk for completed suicide. According to a study, adolescents with a history of cyberbullying were 11.5 times more likely to report suicidal ideation compared to adolescents without any bullying experiences. 17 A recently published study found that increased weekend screen time was associated with higher child-reported suicidality while increased parental supervision and positive school involvement were found to be associated with a decrease in child reported suicidality. 18 Conflicts and dysfunction in families are also associated with an increase in the risk of suicidal behaviors in youth. 18 Other risk factors include a history of adoption, 19 male gender, and a history of physical or sexual abuse. 20

Adolescence is also the time when many youth may experiment with substances which may be mood-altering. In a systematic review and meta-analysis published in February 2019 that involved 23,317 adolescents and 11 studies, use of cannabis in adolescence did have an increased risk having depression and suicidal concerns even later in life. 21 Rates of cannabis use in individuals aged 18–29 years have almost doubled between 2001–2002 to 2012–2013 from 10.5%–21.2%. 22 In August 2019, the U.S. Surgeon General also put out a Health Advisory on “Marijuana Use and Developing Brain” stressing importance of need for protecting youth and pregnant women. 23 Educating teenagers about the risks of cannabis and providing resources for youth to teach them skills to resist peer pressure and getting them access to other prevention programs should be a key component in program implementation. These findings should be considered in developing public health policy and prevention programs.

Treatment and Management

For management of suicide in youth, prevention is the key. In public health there are three major categories of prevention: primary, secondary, and tertiary prevention.

In primary prevention the main target is the general population of youth before developing suicidal thoughts, gestures, or actions. This can include a wide range of interventions, one of which is legislative policies restricting access to firearms. 24 Adolescent suicide by firearm kills more than 1,000 10–19 years old children and adolescents annually in the U.S. 25 This article is not necessarily against the second amendment constitutional right to “keep in bear arms.” Citizens of Missouri have the right to protect themselves and many Missouri families enjoy hunting. However, it is a crucial for caregivers of youth to know that the mere presence of firearms in a household increases the suicide risk to all children at home. 26 Caregivers must appreciate their responsibility in preventing gun access to children, 27 since suicide in youth is generally more impulsive and with lower intent level compared to adults. 28 Another crucial intervention is educating youth against substance use and resisting peer pressure. Studies have shown adolescent cannabis consumption was associated with increased risk of developing depression and suicidal behavior even in the absence of a premorbid condition. 29

Other primary preventative interventions include construction barriers to where suicide could be committed by jumping, detoxification of domestic gas, restriction of pesticides, use of lower toxicity antidepressants, restricting sales of lethal hypnotics. 30 In general, children and adolescents need to be educated about the seriousness of suicide, making suicidal statements, the seriousness of bullying and cyber bullying.

In secondary prevention, the main goal is early identification of children and adolescents at risk for suicide and then referring them for assessment and treatment. 24 Please refer to list of resources for the state of Missouri at the end of this article. Thus, training individuals who could have contact with high risk children and adolescents is imperative. 31 For example, school teachers, school counselors, parents, foster parents, staff in residential facilities, staff in the juvenile system, pediatricians, ER providers, etc., are trained to recognize at-risk youth. They are encouraged to ask them directly about suicidal thoughts and intentions 32 and then refer them to mental health providers.

In tertiary prevention, the goal is to prevent suicidal actions. This typically occurs after youth have been identified as a high-risk individual and have been referred to mental health. Numerous randomized clinical trials showed that cognitive behavioral therapy (CBT) and other psychotherapies are effective in reducing suicidal ideations and attempts. 33 CBT is a form of talk therapy that works on changing cognitive distortions which are negative perceptions of reality. Dialectical behavioral therapy (DBT) is a subtype of CBT. It is an evidence-based therapy that has also been proven to reduce suicide attempts in adolescents. 34 , 35 DBT adds emphasis on emotional regulation, grounding techniques and interpersonal relationships.

The combination of psychopharmacology (medication management) with psychotherapy shows improvement of depression and suicidality scales which was found to be similar to those observed in non-suicidal children. 36 Another tertiary preventative strategy is developing a safety plan with the patient. It is a written list of coping strategies and support resources that the patient can use when endorsing suicidal thoughts. 37

Resources in Missouri

Crisis Text Line

Text HELLO to 741741 and speak anonymously to a crisis counselor. FREE, 24/7 support

National Suicide Prevention Lifeline

800-273-8255

TLC (Talk, Listen Care) Warmline

4-10 pm 7/365

Local: 573-651-3642

Toll Free: 877-626-0638

Mental Health Association of the Heartland Compassionate Ear Warmline

Local: 913-281-2251

Toll-free: 866-927-6327

English: 4–10 pm 365

Spanish: 5–8 pm M-F

Depressive, Manic-Depressive Association of St. Louis Friendship Line

Toll-free: 866-525-1442

Local: 314-652-6105

Central Missouri Crisis Hotline

Toll-free: 800-833-3915

National Alliance on Mental Illness Missouri Warmline

Local: 573-624-7727

Toll Free: 800-374-2138

Hours: 9 am–9 pm M–F

Ravi Shankar, MD, (above), MSMA member since 2014, is Assistant Professor, Director for both Child & Adolescent Psychiatry Fellowship and Psychiatry Clerkship. Rasha El Kady, MD, is Assistant Professor. Arpit Aggarwal, MD, is Assistant Professor and Medical Director of the Psychiatric Center Assessment Unit. All are in the Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri.

None reported.

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The True Cause of Death

• 1 Division of Geriatrics, Department of Medicine, University of California, San Francisco

I had met him at the Over 60 Health Center, a clinic founded by and created for the Gray Panthers, to serve the aging Black Panthers and others in the community. And now a short decade later, he is gone. A self-described lifelong revolutionary, a Black Panther and member of the Black August organizing committee, Roy’s life was filled with stories, and those stories culminating into his immediate cause of death—metastatic cancer. His other underlying medical issues: hepatitis C and a rare spinal cord condition that contributed to unrelenting functional decline. Thinking about his life and what led to this death, I reflected on the day he came to establish care with me. I remember learning of the years of fragmented care, the years of struggle finding safe and affordable housing, and I remember him adjusting to a progressive disability. Life took on twisty turns, and his care again became disrupted after my departure from the community health center, my own father’s death, the birth of my daughter, and then a global pandemic.

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Perissinotto CM. The True Cause of Death. JAMA. 2022;328(1):19–20. doi:10.1001/jama.2022.10406

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Of Death Summary

Of death analysis, critical appreciation:, more from francis bacon.

Approaching Death: Improving Care at the End of Life (1997)

Chapter: 10 conclusions and recommendations, 10 conclusions and recommendations.

Our lives are time travel, moving in one direction only. We accompany one another as long as we can; as long as time grants us.

Joyce Carol Oates, A Letter to My Mother , 1996

We go toward something that is not yet.

Paul Tillich, The Eternal Now , 1959

Dying is at once a fact of life and a profound mystery. Death comes to all, yet each person experiences it in ways that are only partly accessible to the family member or physician, the researcher or philosopher. In principle, humane and skillful care for the dying is a social obligation as well as a personal offering from those directly involved. In reality, both society and individuals fall short of what is reasonably, if not simply, achievable.

Evidence and experience both indicate that much dying is far harder than it should be. Like the mythic king Tantalus, who reached for fruit and water just beyond his grasp, the dying person has too often been destined to seek but not find a pain-free and peaceful death. Such a fate need not be; better deaths are possible now.

This is not to claim that dying and death can be made easy, although certain illnesses tend to bring less-difficult deaths than others; nor is it to suggest that caring well for those approaching death can be made an exact science or flawless art. Caring well involves a frequently stressful, imperfect effort to balance science with sentiment, honesty with hope, patterns of care with room for exceptions.

This report has identified ways in which clinicians, educators, and communities do not care adequately for those approaching death. It has pointed to steps that can improve care at the end of life and sustain improvements through difficult times. It has also highlighted the reasons for believing that professionals, policymakers, and the public are ready to support such steps. These reasons range from the examples of well-known men and women facing death with grace to the focus on deficiencies in care

stimulated by the debate over assisted suicide. In sum, the timing appears right to press for a vigorous societal commitment to improve care for the dying. Such a commitment would motivate and sustain local and national efforts to strengthen and apply the existing knowledge base, reform procedures and policies that impede good care for the dying, and stress the caring functions of health delivery systems.

Today and Tomorrow

The preceding chapters have profiled important aspects of dying in America. They have noted that three-fourths of those who die are elderly and that most people who die are covered by Medicare or other federal, state, or local programs for older, disabled, or impoverished people. Compared to earlier times, death now comes more often in old age from a chronic or progressive disease. Most deaths occur in institutions, mainly hospitals and, to a lesser extent, nursing homes. The proportion of people who die at home is, however, increasing. Only a minority of all deaths involve people cared for by formal hospice programs, and the majority of these involve cancer diagnoses. All patients can potentially benefit from good palliative care, but hospice programs as organized and financed in the United States are most applicable to those with relatively predictable prognoses.

Although specifics may vary according to the nature of a person's disease and his or her personal circumstances, care for dying people and those close to them has several broad dimensions: physical, psychological, spiritual, and practical. Each of these dimensions is intertwined in the key processes of care, which include determining and communicating diagnosis and prognosis, establishing goals and plans, and fitting palliative and other care to these goals. The way care is organized, financed, monitored, and regulated affects how these processes are carried out in different settings for different kinds of patients.

The twenty-first century will bring new realities as well as continuing problems and opportunities in care at the end of life. It will undoubtedly deliver improvements in what medical science can do to prevent and relieve distress for those approaching death, but demographic, economic, and other trends will strain systems that already find it difficult to deliver what clinical knowledge currently allows—and what compassion should grant.

The committee focused primarily on trends and expectations relevant to care for dying patients during the next 10 to 20 years. One of these expectations is that policymakers and others will need to prepare during this period for the final demographic consequences of the post-World War II baby boom. The oldest members of the baby boom generation will reach age 65 in the year 2011, and the youngest members will do so nearly 20

years later. Barring dramatic unexpected developments, older adults will constitute a larger proportion of the population than today, and the absolute numbers of dying patients will be much larger. In the face of an ever-increasing population with chronic conditions, the current system, with its emphasis on acute curative care, will fail to provide needed long-term chronic care and palliative and support services. Although health care and social service providers have a long lead time compared with the educators and communities who had to scramble to provide schooling for the baby boom generation, the difficulties that policymakers are having with Social Security and Medicare do not bode well for the nation's ability to cope with an aging population.

In addition, continuing increases in longevity will mean that the proportion of those dying past age 75 will increase. The impact on the health care system and society on larger numbers of people dying in older old age will depend in part on their health status in the years before death. The "compression of morbidity hypothesis," for which the evidence is ambiguous, posits that an increase in healthier life styles means that people will experience disabling conditions for a smaller proportion of the years before death than today. Even if this does occur, the overall impact of the larger proportion of older people and their longer life span will still pose enormous challenges for social and health care systems.

Demographic politics are likely to be complex in coming years. On the one hand, the so-called senior lobby should be strengthened by the "baby boom" cohort. The "baby boomers," throughout their childhood, youth, and early middle age, have drawn public attention to their needs and concerns. On the other hand, the burden on the smaller working-age population of supporting its elders raises the specter of a generational backlash (even though younger people could also be burdened if the social support available to their aging parents is reduced). Such a backlash could take many forms, including means-testing Social Security benefits or less sympathy for supportive services for frail elderly people, those with serious disabilities, and people who are dying.

Cultural trends add further complexity to demographic politics. Immigrants, who tend to be young and have more children than native-born Americans, have been a major source of growth in the total U.S. population (NRC, 1997). Nonhispanic Caucasians—now a majority—are a decreasing proportion of the U.S. population. Thus, the large elderly population in the first decades of the next century will be dependent on a smaller and more culturally diverse population of younger people.

As described in preceding chapters, health care in the United States is undergoing major changes. The use of hospital services has dropped significantly, and further declines are likely, particularly in those areas with continued relatively high rates of use. Hospital care will likely be less available

to dying patients, potentially including some who could benefit from such care as well as many who will do better with alternatives.

Despite indications that health care spending increases have moderated from years past, the pressure to cut health care costs does not appear to be abating. In particular, given the bleak financial picture for Medicare and the significant portion of spending accounted for by beneficiaries in their last year of life, these constraints may be manifested in some degree of age-based rationing. That is, older people could be denied services simply because of their age, without regard to their life expectancies, function, or expected benefit from care. Decreased access to advanced technologies intended to prolong life could be a highly visible issue, although it is relatively unimportant for the great majority of those dying at an advanced age.

If successful, increased efforts to shift Medicare beneficiaries into various forms of managed care will test these entities, whose enrollment now is overwhelmingly concentrated in younger, healthier age groups. Potential problem areas include payment, contracting, and utilization review mechanisms that limit access to clinicians and care teams experienced in palliative care, patient scheduling norms that limit time for careful clinician-patient communication, marketing strategies intended to discourage enrollment or encourage disenrollment by seriously ill people, drug formularies that exclude or restrict important medications, and bureaucratic hurdles that discourage people from seeking care or preclude them from receiving requested services. One characteristic of many managed care organizations is an emphasis on moving more responsibility for diagnosis and patient management to primary care clinicians, including nurse practitioners, nurses, and other nonphysicians. How well this will work for seriously ill and elderly patients is not yet clear. A major role for nurses and other health care professionals is, however, already well tested in hospice, social health maintenance organizations, and other settings that care for patients dying of advanced progressive diseases, particularly cancer, and for frail elderly people.

As well as focusing attention on competing ethical and policy values, this prospect of constrained resources underscores the need for more valid and reliable tools for assessing health status, measuring outcomes, and linking them to health interventions. Considerable progress is being made in this arena. In addition, improved computer-based information and decision support systems promise several benefits. At the level of the individual, they will help patients, families, and clinicians in making more informed decisions about care at the end of life. At the system or societal level, they will strengthen structures and processes of accountability involving health care providers, purchasers, patient/consumers, and public officials.

Moreover, advanced information and communications technologies may make health care more accessible for some who face geographic or

other barriers to care. Although the potential for practical, effective, and affordable "medicine at a distance" is more promised than proved, telemedicine could help bring palliative and other expertise and services to homes, nursing homes, and other places where they are not very available today (IOM, 1996e). People who have chronic and advanced illnesses but do not qualify for hospital inpatient care could benefit.

Findings and Recommendations

Although the committee found many problems, it also found much that was good and improving in care for those approaching death. It was impressed by the principles, aspirations, and practices being advanced by the field of palliative medicine and being implemented or attempted through interdisciplinary care teams in varied settings, including hospices, hospitals, nursing homes, and private homes. More effort is now being devoted to understanding differences in people's paths toward death and developing programs that are flexible enough to accommodate these differences. In addition to dedicated professionals, many volunteers contribute their time and energy to provide emotional and practical support to dying patients and those close to them. People from a variety of backgrounds have also joined together to direct the attention of policymakers and ordinary citizens to the need to remove barriers to good care created by laws, regulations, organizational practices, and lack of supportive community resources.

Care for the dying should also benefit from ongoing efforts to improve continuity of care, strengthen information systems, prevent health problems, and create accountability for the quality of care. The developing fields of outcomes measurement can make important contributions to the care of the dying by teaching us how to conceptualize and measure quality of life and well-being for those approaching death. Quality improvement strategies are helping to identify and remedy system problems that impede good care. The committee is encouraged by the growing interest in end-of-life issues as recently evidenced by the publication of books and articles for lay and professional audiences, the commitment of foundation resources to support research and education, and the organization of conferences, working groups, and other initiatives sponsored by professional societies and others.

Deficiencies in Care at the End of Life

Notwithstanding these positive features, the committee concluded that very serious problems remain. Indeed, in this committee's view, if physician and hospital performance in infection control were as poor as it is, for

example, in pain management, the ensuing national outcry would create an immediate demand for responses from clinicians, managers, and educators.

The committee identified four broad deficiencies in the current care of people with life-threatening and incurable illnesses. First , too many people suffer needlessly at the end of life both from errors of omission—when caregivers fail to provide palliative and supportive care known to be effective—and from errors of commission—when caregivers do what is known to be ineffective and even harmful. As reported in Chapter 3 , studies have repeatedly indicated that a significant proportion of dying patients and patients with advanced disease experience serious pain, despite research identifying a range of effective pharmacological and other options for relieving most pain. Other symptoms are less well studied, and more research on symptom prevalence and management is needed, but the information available to the committee suggested similar care problems. Deficiencies in the application of existing knowledge to prevent and manage pain and other distressing symptoms stem from an unfortunate mix of ignorance about effective pharmacological and other interventions, misplaced concern about opioid addiction, and inadequate attention to people's quality of life while dying. These problems are reinforced by care systems that are not structured to provide the clinical expertise, reliability, continuity, and emotional support needed by people approaching death. Cultural biases and fears about illness, disability, and death may also contribute to avoidance of dying patients and those close to them.

In perverse counterpoint to the problem of undertreatment, the aggressive use of ineffectual and intrusive interventions may prolong and disfigure the period of dying. Some of this care is knowingly accepted; some is provided counter to patients' wishes; much is probably provided and accepted with little knowledge or consideration of its probable benefits and burdens. Medical culture still tolerates and even rewards the misapplication of life-sustaining technologies while slighting the prevention and relief of suffering.

Second , legal, organizational, and economic obstacles conspire to obstruct reliably excellent care at the end of life. Despite some reforms, outdated and scientifically flawed drug-prescribing laws, regulations, and interpretations by state medical boards still frustrate and intimidate physicians who wish to relieve their patients' pain. Addiction to appropriately prescribed opioids is virtually nonexistent whereas their underprescription for pain is well documented. Organizational structures often interfere with the coordination and continuity of care and impede the further development and application of palliative care strategies in patient care, professional education, and research.

Financial incentives also discourage health care practitioners and providers from rearranging care so that it serves dying patients well. Tradi-

tional financing mechanisms—including arrangements based on discounted fees—provide incentives for the overuse of procedural services and the under-provision of the assessment, evaluation, management, and supportive services so important for people with serious chronic or progressive medical problems. Medicare hospice benefits have helped fill gaps for a small segment of dying patients, but many more have conditions that do not readily fit the current hospice model or requirements. Alternatives to fee-for-service financing in combination with restrictive administrative practices pose different potential hazards that are largely unstudied as they affect seriously and incurably ill people.

Third , the education and training of physicians and other health care professionals fails to provide them with the knowledge, skills, and attitudes required to care well for the dying patient. Many deficiencies in practice stem from fundamental prior failures in professional education. Despite encouraging signs of change, most clinicians-in-training experience and learn too little of the caring that helps people to live well while dying. Undergraduate, graduate, and continuing medical education do not sufficiently prepare health professionals to recognize the final phases of illnesses, construct effective strategies for care, communicate with patients and those close to them, and understand and manage their own emotional reactions to death and dying.

Fourth , current knowledge and understanding are inadequate to guide and support the consistent practice of evidence-based medicine at the end of life. In addition to existing knowledge not being well used, we still know too little about how people die; how they want to die; and how different kinds of physical, emotional, and spiritual care might better serve the dying and those close to them. Biomedical and clinical research have emphasized the development of knowledge that contributes to the prevention, detection, or cure of disease and to the prolongation of life. Research on the end stages of diseases and the physiological bases of symptoms and symptom relief has been less well supported. Epidemiological and health services research has likewise not provided a strong base for understanding the degree to which people suffer symptoms (except, perhaps, cancer pain), experience death alone rather than in the company of those who care, comprehend diagnostic and prognostic information, and achieve a dying that is reasonably consistent with their preferences, community norms, and palliative care principles. Methods development is important to define and measure outcomes other than death (including patient and family perceptions) and to monitor and improve the quality of care for those approaching death.

More generally, it seems that this nation has not yet discovered how to talk realistically but comfortably about the end of life, nor has it learned how to value the period of dying as it is now experienced by most people.

For most of human history, death came fairly quickly in childhood or at adult ages that today seem relatively young. As the twentieth century ends, most people in economically advanced countries live fairly healthy lives into older age but then experience progressive disability for some time before they die. Except what can be inferred from newspaper obituary pages, this reality is largely shunned by the news, information, and entertainment media as distasteful or uninteresting. One result is an unhelpful combination of public fear, misinformation, and oversimplification that views misery as inescapable, pain as unavoidable, and public spending as misdirected for people who are approaching death.

Recommendations and Future Directions

The committee developed seven recommendations directed at different decisionmakers and different deficiencies in care at the end of life. These recommendations and a brief explanation follow. Each applies generally to people approaching death, including those for whom death is imminent and those with serious, eventually fatal illnesses who may live for some time.

RECOMMENDATION 1: People with advanced, potentially fatal illnesses and those close to them should be able to expect and receive reliable, skillful, and supportive care . Educating people about care at the end of life is a critical responsibility of physicians, hospitals, hospices, support groups, public programs, and media. Most patients and families need information not only about diagnosis and prognosis but also about what support and what outcomes they should reasonably be able to anticipate. They should, for example, not be allowed to believe that pain is inevitable or that supportive care is incompatible with continuing efforts to diagnose and treat. They should learn—before their last few days of life—that supportive services are available from hospices and elsewhere in the community and that those involved in their care will help arrange such services. Patient and family expectations and understanding will be aided by advance care planning that considers needs and goals, identifies appropriate surrogate decisionmakers, and avoids narrow preoccupation with written directives. To these ends, health care organizations and other relevant parties should adopt policies regarding information, education, and assistance related to end-of-life decisions and services. For those who seek to build public understanding of dying as a part of life and to generate public demand for reliable and effective supportive services, one model can be found in the perspectives, spirit, and strategies that have guided efforts to promote effective prenatal care and develop mother- and family-oriented arrangements for childbirth.

RECOMMENDATION 2: Physicians, nurses, social workers, and other health professionals must commit themselves to improving care for dying patients and to using existing knowledge effectively to prevent and relieve pain and other symptoms. Most patients depend on health care professionals to prevent and manage the varying physical and psychological symptoms that accompany advanced illness. To meet their obligations to their patients, practitioners must hold themselves and their colleagues responsible for using existing knowledge and available interventions to assess, prevent, and relieve physical and emotional distress. Unrelieved pain and other symptoms are the most evident problems that practitioners can readily avoid for the great majority of patients, but problems with communication, appropriate regard for patient and family wishes, and timely referral to palliative care specialists or teams are other areas in need of improvement. When good practice is hindered by organizational, financial, or legal impediments, health professionals have the responsibility as individuals and members of larger groups to advocate for system change.

RECOMMENDATION 3: Because many deficiencies in care reflect system problems, policymakers, consumer groups, and purchasers of health care should work with health care providers and researchers to

Although individuals must act to improve care at the end of life, systems of care must be changed to support such action. System change requires the involvement of public and private purchasers of care, regulators, and others whose policies and practices may create incentives for inappropriate care and barriers to excellent care.

Better information systems and tools for measuring outcomes and evaluating care are critical to the creation of effective and accountable systems of care and to the effective functioning of both internal and external systems of quality monitoring and improvement. Reliable and valid information about quality of care should be available to patients, purchasers, and ac-

crediting organizations, but organizations also need to audit their structures and processes for problem areas and commit themselves to improving care on an ongoing basis. Problem areas include insufficient numbers and types of properly trained personnel, nonexistent or inadequate protocols for symptom assessment and management, and poor procedures for evaluating the need for patient transfers or referrals and for carrying out such transfers without harm to patients. The committee supports the development of guidelines for clinical practice that assist clinicians in preventing and relieving symptoms and in managing the end stages of specific diseases.

Policymakers and purchasers need to consider both the long-recognized deficiencies of traditional fee-for-service arrangements and the less thoroughly understood strengths and limitations of alternatives, including various kinds of capitated and per case payment methods that apply in diverse ways to individual practitioners, interdisciplinary care teams, specific institutions, networks of providers, or integrated systems of care. Particularly in need of attention are the levels of payment for home and nursing home visits by physicians, the interpretation of evaluation and management codes, the lack of diagnosis- or condition-related adjustments in hospice payments for both home and inpatient care, and other financing incentives that may discourage hospices or health plans from enrolling sicker patients. In addition, reimbursement methods and related incentives should encourage continuity of care that supports patients all the way through death and reduces disconnected and episodic care. Health care professionals and organizations also need to formulate ethical guidelines to guard against possible conflicts of interest in capitated and other care systems.

The problems with laws relating to prescribing practices are twofold. One problem is outdated, scientifically flawed laws and regulations themselves. The other problem is clinician, regulator, and public misunderstanding of the appropriate use of opioids. State medical societies, licensing boards, legislative committees, and other groups should cooperate to review state laws, regulations, board practices, and physician attitudes and practices to identify problem areas and then devise revisions in those statutes and regulations that unduly burden clinical management of pain. Regulatory review and revision should be accompanied by educational efforts to increase scientifically and clinically based knowledge and correct misperceptions about the appropriate medical use of opioids and about the biological mechanisms of opioid dependence, addiction, and pain management. Legal change should help—but cannot be relied upon alone—to correct undertreatment.

RECOMMENDATION 4: Educators and other health professionals should initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have the relevant attitudes, knowledge, and

skills to care well for dying patients. Dying is too important a part of life to be left to one or two required (but poorly attended) lectures, to be considered only in ethical and not clinical terms, or to be set aside on the grounds that medical educators are already swamped with competing demands for time and resources. Every health professional who deals directly with patients and families needs a basic grounding in competent and compassionate care for seriously ill and dying patients. For clinicians and others to be held truly accountable for their care of the dying, educators must be held accountable for what they teach and what they implicitly and explicitly honor as exemplary practice. Textbooks and other materials likewise need revision to reflect the reality that people die and that dying patients are not people for whom "nothing can be done." As described in Chapter 8 , a number of promising curriculum models exist, and others are being developed and tested.

RECOMMENDATION 5: Palliative care should become, if not a medical specially, at least a defined area of expertise, education, and research. The objective is to create a cadre of palliative care experts whose numbers and talents are sufficient to (a) provide expert consultation and role models for colleagues, students, and other members of the health care team; (b) supply educational leadership and resources for scientifically based and practically useful undergraduate, graduate, and continuing medical education; and (c) organize and conduct biomedical, clinical, behavioral, and health services research. More generally, palliative care must be redefined to include prevention as well as relief of symptoms. Attention to symptoms should begin at earlier points during the trajectory of an illness because early treatment may well contribute to lessening pain at the end of life. The model for palliative care stresses interdisciplinary, comprehensive, and continuing care of patients and those close to them.

RECOMMENDATION 6: The nation's research establishment should define and implement priorities for strengthening the knowledge base for end-of-life care. The research establishment includes the National Institutes of Health, other federal agencies (e.g., the Agency for Health Care Policy and Research, the Health Care Financing Administration, the National Center for Health Statistics), academic centers, researchers in many disciplines, pharmaceutical companies, and foundations supporting health research. Their active support and involvement is necessary to advance basic and clinical research on the physiological mechanisms and treatment of symptoms common during the end of life, including neuropsychiatric problems. To extend understanding of quality-of-life issues in the treatment of advanced disease, those supporting clinical trials should encourage the collection of more information on the quality of life of those who die while

enrolled in such trials. A further step is to support more research on the physiological mechanisms and treatment of symptoms common during the end of life, including neuropsychiatric problems. Pain research appears to supply a good model for this enterprise to follow. In addition, pathways need to be developed to further the dissemination and replication of proven health care interventions and programs. Demonstration projects to test new methods of financing and organizing care should be a priority for the Health Care Financing Administration. To encourage change in the attitudes and understandings of the research establishment, the committee urges the National Institutes of Health and other public agencies to take the lead in organizing a series of workshops, consensus conferences, and agenda-setting projects that focus on what is and is not known about end stage disease and symptom prevention and treatment and that propose an agenda for further research. For the Agency for Health Care Policy and Research, the committee encourages support for the dissemination and replication of proven health care interventions and programs through clinical practice guidelines and other means.

RECOMMENDATION 7: A continuing public discussion is essential to develop a better understanding of the modern experience of dying, the options available to dying patients and families, and the obligations of communities to those approaching death. Individual conversations between practitioners and patients are important but cannot by themselves provide the supportive environment for the attitudes and actions that make it possible for most people to die free from avoidable distress and to find the peace or meaning that is significant to them. Although efforts to reduce the entertainment and news media's emphasis on violent or sensational death and unrealistic medical rescue have not been notably successful, a modicum of balance has recently been provided by thoughtful analyses; public forums; and other coverage of the clinical, emotional, and practical issues involved in end-of-life care. Regardless of how the current, highly publicized policy debate over physician-assisted suicide is resolved, the goal of improving care for those approaching death and overcoming the barriers to achieving that goal should not be allowed to fade from public consciousness. Much of the responsibility for keeping the public discussion going will rest not with the media but with public officials, professional organizations, religious leaders, and community groups.

Finally, the committee agreed that it was not prepared to take a position on the legality or morality of physician-assisted suicide. The issue should not, in any case, take precedence over those reforms to the health care system that would improve care for all dying patients. The goal of those who favor legalizing physician-assisted suicide is to promote patient autonomy, but true autonomy is not possible when significant numbers of

people have the limited choice between suicide or continued suffering. If the laws permitting physician-assisted suicide are implemented at the state level, careful monitoring of their consequences for the quality of care and the public's trust in health care will be very important.

Concluding Thoughts

Improving care at the end of life will require many changes in attitudes, policies, and actions. Such changes will involve a multitude of people and institutions that have a role in making and implementing decisions about patient care or in structuring the environments in which such decisions are reached and realized. Clearly, what patients and their families know, expect, and desire is important. Health care professionals play critical roles in diagnosis, communication, guidance and direction, treatment, negotiation, and advocacy for patients at many levels. Decisions by health plan managers, institutional administrators, and governmental officials shape and often impede the ability of patients, families, and clinicians to construct a care plan that serves the dying person well.

In general, changes in systems of care—not just individual beliefs and actions—are necessary if real gains are to be made in helping people live well despite fatal illness. Such widespread changes depend in part on a stronger social consensus on what constitutes appropriate and supportive care for those approaching death. Widely publicized—albeit not necessarily typical—instances of patient and family powerlessness to stop what they see as futile and painful treatments reflect a lack of such consensus. Paradoxically, this lack of consensus also is evident when patients or families demand treatments that practitioners see as useless, counterproductive, or even inhumane. It similarly reveals itself in a health care delivery and financing system that still rewards life-prolonging interventions (even when they will be ineffectual) and slights palliative and supportive services for those for whom life-extending treatment is neither helpful nor desired.

Freud may have been right that "our unconscious does not believe in its own death; it behaves as if immortal" (Freud, 1915, in Freud, 1959, p. 304). The committee was optimistic, nonetheless, that this society would cultivate the conscious intelligence and spirit to recognize the reality of death and the likelihood that it will bring distress. It likewise was optimistic that people would work together to create humane systems of care that assure the consistent use of existing knowledge to prevent and relieve suffering and that support efforts to provide people the right care at the right time in the right way. The analyses, conclusions, and recommendations presented here are offered with optimism that we can, individually and together, "approach" death constructively and create humane care systems that people can trust to serve them well as they die.

When the end of life makes its inevitable appearance, people should be able to expect reliable, humane, and effective caregiving. Yet too many dying people suffer unnecessarily. While an "overtreated" dying is feared, untreated pain or emotional abandonment are equally frightening.

Approaching Death reflects a wide-ranging effort to understand what we know about care at the end of life, what we have yet to learn, and what we know but do not adequately apply. It seeks to build understanding of what constitutes good care for the dying and offers recommendations to decisionmakers that address specific barriers to achieving good care.

This volume offers a profile of when, where, and how Americans die. It examines the dimensions of caring at the end of life:

• Determining diagnosis and prognosis and communicating these to patient and family.
• Establishing clinical and personal goals.
• Matching physical, psychological, spiritual, and practical care strategies to the patient's values and circumstances.

Approaching Death considers the dying experience in hospitals, nursing homes, and other settings and the role of interdisciplinary teams and managed care. It offers perspectives on quality measurement and improvement, the role of practice guidelines, cost concerns, and legal issues such as assisted suicide. The book proposes how health professionals can become better prepared to care well for those who are dying and to understand that these are not patients for whom "nothing can be done."

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5 moving, beautiful essays about death and dying

by Sarah Kliff

It is never easy to contemplate the end-of-life, whether its own our experience or that of a loved one.

This has made a recent swath of beautiful essays a surprise. In different publications over the past few weeks, I’ve stumbled upon writers who were contemplating final days. These are, no doubt, hard stories to read. I had to take breaks as I read about Paul Kalanithi’s experience facing metastatic lung cancer while parenting a toddler, and was devastated as I followed Liz Lopatto’s contemplations on how to give her ailing cat the best death possible. But I also learned so much from reading these essays, too, about what it means to have a good death versus a difficult end from those forced to grapple with the issue. These are four stories that have stood out to me recently, alongside one essay from a few years ago that sticks with me today.

My Own Life | Oliver Sacks

As recently as last month, popular author and neurologist Oliver Sacks was in great health, even swimming a mile every day. Then, everything changed: the 81-year-old was diagnosed with terminal liver cancer. In a beautiful op-ed , published in late February in the New York Times, he describes his state of mind and how he’ll face his final moments. What I liked about this essay is how Sacks describes how his world view shifts as he sees his time on earth getting shorter, and how he thinks about the value of his time.

Before I go | Paul Kalanithi

Kalanthi began noticing symptoms — “weight loss, fevers, night sweats, unremitting back pain, cough” — during his sixth year of residency as a neurologist at Stanford. A CT scan revealed metastatic lung cancer. Kalanthi writes about his daughter, Cady and how he “probably won’t live long enough for her to have a memory of me.” Much of his essay focuses on an interesting discussion of time, how it’s become a double-edged sword. Each day, he sees his daughter grow older, a joy. But every day is also one that brings him closer to his likely death from cancer.

As I lay dying | Laurie Becklund

Becklund’s essay was published posthumonously after her death on February 8 of this year. One of the unique issues she grapples with is how to discuss her terminal diagnosis with others and the challenge of not becoming defined by a disease. “Who would ever sign another book contract with a dying woman?” she writes. “Or remember Laurie Becklund, valedictorian, Fulbright scholar, former Times staff writer who exposed the Salvadoran death squads and helped The Times win a Pulitzer Prize for coverage of the 1992 L.A. riots? More important, and more honest, who would ever again look at me just as Laurie?”

Everything I know about a good death I learned from my cat | Liz Lopatto

Dorothy Parker was Lopatto’s cat, a stray adopted from a local vet. And Dorothy Parker, known mostly as Dottie, died peacefully when she passed away earlier this month. Lopatto’s essay is, in part, about what she learned about end-of-life care for humans from her cat. But perhaps more than that, it’s also about the limitations of how much her experience caring for a pet can transfer to caring for another person.

Yes, Lopatto’s essay is about a cat rather than a human being. No, it does not make it any easier to read. She describes in searing detail about the experience of caring for another being at the end of life. “Dottie used to weigh almost 20 pounds; she now weighs six,” Lopatto writes. “My vet is right about Dottie being close to death, that it’s probably a matter of weeks rather than months.”

Letting Go | Atul Gawande

“Letting Go” is a beautiful, difficult true story of death. You know from the very first sentence — “Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die” — that it is going to be tragic. This story has long been one of my favorite pieces of health care journalism because it grapples so starkly with the difficult realities of end-of-life care.

In the story, Monopoli is diagnosed with stage four lung cancer, a surprise for a non-smoking young woman. It’s a devastating death sentence: doctors know that lung cancer that advanced is terminal. Gawande knew this too — Monpoli was his patient. But actually discussing this fact with a young patient with a newborn baby seemed impossible.

"Having any sort of discussion where you begin to say, 'look you probably only have a few months to live. How do we make the best of that time without giving up on the options that you have?' That was a conversation I wasn't ready to have," Gawande recounts of the case in a new Frontline documentary .

What’s tragic about Monopoli’s case was, of course, her death at an early age, in her 30s. But the tragedy that Gawande hones in on — the type of tragedy we talk about much less — is how terribly Monopoli’s last days played out.

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How Do You View Death?

Does thinking about your own mortality make you appreciate life? Or does the thought fill you with dread?

By Nicole Daniels

Note to Teachers: We don’t often take on the subject of death, but with the world experiencing a devastating pandemic, we thought this article might help students think about their own understanding of mortality.

This past year has been filled with death: More than 300,000 people in the United States and 1.6 million worldwide have died from the coronavirus.

Has the pandemic changed your understanding of death and dying? Have you had to grieve the death of a loved one? Has it made you consider your own mortality more? Has it made you appreciate the impermanence of life? Or have the staggering numbers made you feel numb?

In “ What Is Death? ,” Dr. BJ Miller writes about how the coronavirus pandemic has transformed our understanding of mortality and offers several frameworks for thinking about death:

This year has awakened us to the fact that we die. We’ve always known it to be true in a technical sense, but a pandemic demands that we internalize this understanding. It’s one thing to acknowledge the deaths of others, and another to accept our own. It’s not just emotionally taxing; it is difficult even to conceive. To do this means to imagine it, reckon with it and, most important, personalize it. Your life. Your death. Covid-19’s daily death and hospitalization tallies read like ticker tape or the weather report. This week, the death toll passed 300,000 in the United States. Worldwide, it’s more than 1.6 million. The cumulative effect is shock fatigue or numbness, but instead of turning away, we need to fold death into our lives. We really have only two choices: to share life with death or to be robbed by death. Fight, flight or freeze. This is how we animals are wired to respond to anything that threatens our existence. We haven’t evolved — morally or socially — to deal with a health care system with technological powers that verge on godly. Dying is no longer so intuitive as it once was, nor is death necessarily the great equalizer. Modern medicine can subvert nature’s course in many ways, at least for a while. But you have to have access to health care for health care to work. And eventually, whether because of this virus or something else, whether you’re young or old, rich or poor, death still comes. What is death? I’ve thought a lot about the question, though it took me many years of practicing medicine even to realize that I needed to ask it. Like almost anyone, I figured death was a simple fact, a singular event. A noun. Obnoxious, but clearer in its borders than just about anything else. The End. In fact, no matter how many times I’ve sidled up to it, or how many words I’ve tried on, I still can’t say what it is. If we strip away the poetry and appliqué our culture uses to try to make sense of death — all the sanctity and style we impose on the wild, holy trip of a life that begins, rises and falls apart — we are left with a husk of a body. No pulse, no brain waves, no inspiration, no explanation. Death is defined by what it lacks.

The essay continues:

Beyond fear and isolation, maybe this is what the pandemic holds for us: the understanding that living in the face of death can set off a cascade of realization and appreciation. Death is the force that shows you what you love and urges you to revel in that love while the clock ticks. Reveling in love is one sure way to see through and beyond yourself to the wider world, where immortality lives. A pretty brilliant system, really, showing you who you are (limited) and all that you’re a part of (vast). As a connecting force, love makes a person much more resistant to obliteration. You might have to loosen your need to know what lies ahead. Rather than spend so much energy keeping pain at bay, you might want to suspend your judgment and let your body do what a body does. If the past, present and future come together, as we sense they must, then death is a process of becoming. So, once more, what is death? If you’re reading this, you still have time to respond. Since there’s no known right answer, you can’t get it wrong. You can even make your life the answer to the question.

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Major Causes of Death, Essay Example

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The top four health issues for people living in Florida include exposure to harmful UV rays, a sedentary lifestyle, unhealthy eating habits, and diabetes, according to Florida Charts (Florida Charts, n.d.). Meanwhile, Healthy People 2020 considers the top four health issues to be illnesses related to smoking, obesity, environmental disease triggers, and cancer (Healthy People 2020, n.d.). It is important to consider that even though the health risks identified by Health People 2020 are not the top four concerns for Florida residents, Floridians still encounter all of the problems included in this initiative and it is therefore important for state residents to work towards preventing these health issues as well.

One important overlap between Florida health concerns and national health concerns is that obesity is an issue. While this health concern was listed on the Florida Charts page as individuals living a sedentary lifestyle and engaging in unhealthy eating, habits, it is important to consider that these are the activities that contribute to obesity. Furthermore, obesity contributes to some other health concerns on the watch list, such as cancer. In order to ensure that the overall American population is able to achieve health by 2020, it is therefore likely that the best course of action would be to focus on health diet and exercise for all residents of the nation. Since the modern lifestyle has not changed to accommodate these needs, it is important for every individual to understand the effort that must be put in to accomplish this health. The human body was meant to move and eat properly, not watch television and sit down all day. We must therefore adjust our daily routines to ensure that this is possible.

Florida Charts. (n.d.). Major Causes of Death. Retrieved from http://www.floridacharts.com/charts/SpecReport.aspx?RepID=7226&tn=33

Healthy People 2020. (n.d.). 2020 Topics and Objectives. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/default

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Why We Fear Death and How to Overcome It

You might be surprised by the factors that influence our attitudes toward death..

Posted September 2, 2020 | Reviewed by Abigail Fagan

• What Is Fear?
• Take our Generalized Anxiety Disorder Test
• Find a therapist to combat fear and anxiety

Death—what isn’t there to be afraid of? It’s the ultimate end! But while some people dread death, others accept it as inevitable. So why do some people fear it more than others?

It turns out that the way we think about death can affect how we think and act in daily life. For example, a 2016 study found that fear of death could amplify our desire for revenge and political violence. Palestinian, Israeli, and South Korean participants were prompted to think about personal pain or death, and then asked about their opinions about how specific political conflicts should be resolved. Those who were reminded of death were more likely to support military action than those who only thought about pain.

Fearing death also makes it harder for us to process grief . A recent study found that those who were afraid of death were more likely to have prolonged symptoms of grief after losing a loved one compared to those who had accepted death. For healthcare workers who care for dying patients, their own fear of death may get in the way of effectively communicating with patients and their families.

There are some things that may subtly, or not so subtly, affect how much we fear death.

1. Older people tend to fear death less. You might think this would be the opposite, but this pattern has been found time and time again in research studies. We tend to assume that the older someone is, the closer they seemingly are to death, and therefore the more afraid of it they should be. But interestingly, older age is associated with more acceptance of death .

This could be because older people have experienced more of life, so they have less fear of missing out. Or it might be because they have more experience with witnessing and handling the death of others.

2. Religious belief increases our fear (but it’s complicated). Here’s another counterintuitive one. You may think that religious belief, which usually includes confidence in an afterlife or a greater meaning to life, would make people feel better about the finality of death. But studies have found that those with stronger religiosity , regardless of culture or religion, have a stronger fear of death.

But it’s worth noting that there are also studies that show the opposite.

Some studies have found that, at least among Westerners, those who fear death most are moderately religious . Both non-believers and very religious people feared death less .

Perhaps being moderately religious puts people in the “existential sweet spot” for being afraid of death—they’re not as relaxed as non-believers, but they also don’t hold the same strong convictions about the afterlife that very religious people do. It’s also possible that the egg comes before the chicken—people who particularly fear death seek out religion as a coping mechanism, but they don’t end up being very religious.

3. Experience with danger. Your interactions with danger may also change your fear of death. Though some experiences make you fear death less, too much might increase your fear.

Here’s an example: In a very cool study, researchers recruited beginner, intermediate, and expert skydivers to share their feelings about death. Not surprisingly, beginner skydivers, with only an average of 1 jump under their belt, were scared of death. Intermediate skydivers, with an average of 90 jumps, were a lot less scared. But—and this is the interesting part—expert skydivers, who had jumped over 700 times, were more scared of death than intermediate skydivers.

This shows that simply risking death more doesn’t decrease your fear of it. There may be a learning curve, where getting some experience makes you feel less anxious (maybe because you gain a greater sense of control), but getting a lot of experience makes you more aware that you can’t cheat death after all.

4. Physical health. This one is less surprising: People with better physical health tend to fear death less. Researchers have found that those with better physical health tend to feel like there is more meaning in life. They also tend to have better mental health. These are the factors that make them fear death less . In a way, this can be encouraging even for those who cannot control their physical health. They may still be able to find meaning in life and work on their mental health to decrease their existential dread.

5. Attachment style. Attachment styles refer to ways we think about and behave in close relationships. These are shaped early in life so by the time we’re adults, we’re usually pretty settled into ours. Securely attached people tend to be confiding, dependable, and supportive partners. Insecurely attached people can be overly anxious and controlling, or distant and standoffish, or a mix of both.

When it comes to how they feel about death, people with secure attachment styles fear death less than people with insecure attachment styles. This is interesting because it shows that there’s a relationship and intimacy aspect to the way we think about death.

What can you do to become less afraid of death?

All of this research showing that fear of death may be fluid depending on our beliefs and experiences begs the question: What can we do to fear death less?

Some things that affect your fear of death, like your age, can’t be controlled. And most of us probably can’t (or won’t) go skydiving 90 times. But researchers have found some other things we may be able to do:

1. Help the next generation. The term “generativity” refers to a concern for younger people and a desire to nurture and guide them. When older people have a greater sense of generativity, they tend to also look back on their life without regret or anguish. This, understandably, leads to having less fear of death.

Even if you don’t have children or grandchildren, you can feed your generativity by mentoring younger people in a career or in life. You can volunteer with the Big Brothers Big Sisters program, or tutor a neighborhood kid, or mentor someone in your career field.

2. Don’t avoid the topic. We try to avoid things, like death, that make us uncomfortable, but avoidance can make those things loom even larger in our minds.

An interesting study with funeral directors found that those who had directed more funerals feared death less. Among physicians, more years of experience, and more exposure to death, also led to less fear of death. But even if you’re not a funeral director or healthcare worker, you can still familiarize yourself with death by reading about it or volunteering with organizations that take care of those with terminal illnesses.

3. Have a (simulated) out-of-body or near-death experience. Here’s a fascinating one. Multiple research studies have found that having an out-of-body experience or near-death experience makes people less afraid of death. In the case of near-death experiences , it might be that the things we confront are less scary to us.

In the case of out-of-body experiences , it might give us the sense that we live on even when we are separated from our bodies. While you shouldn’t seek a near-death experience (we don’t want it to end up being not-so-near), you could try out a virtual reality program that simulates an out-of-body experience.

4. Cultivate your meaning in life. Now, this is the tip I think is the most important and impactful.

We know that reminding people of their own mortality tends to make them fear death. But if someone feels a strong sense of having meaning in life, this reminder doesn’t bother them .

Cultivating meaning in life is no simple task, but you can start by identifying your values, which are big-picture driving forces that guide how you move through life. Whether it be creativity , success, or serenity, brainstorm the values that are most important to you and govern your life with these ideas in mind.

Mark Twain said, “The fear of death follows from the fear of life. A man who lives fully is prepared to die at any time.”

This is very wise ! Based on the research, I think it would be more precise to replace “lives fully” with “lives meaningfully.” But for some people, perhaps these are the same. No matter what your meaningful life looks like, start to develop it now, and you’ll be too busy feeling fulfilled to be afraid of death.

A version of this post titled How to Master Your Fear of Death was originally posted on Quick and Dirty Tips.

Jade Wu, Ph.D., is a clinical health psychologist and host of the Savvy Psychologist podcast. She specializes in helping those with sleep problems and anxiety disorders.

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Home — Essay Samples — Literature — Romeo and Juliet — The Cause Of Juliet’s Death In Romeo And Juliet

The Cause of Juliet's Death in Romeo and Juliet

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Published: Mar 5, 2024

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One in 100 deaths is by suicide

Who guidance to help the world reach the target of reducing suicide rate by 1/3 by 2030.

Suicide remains one of the leading causes of death worldwide, according to WHO’s latest estimates, published today in “Suicide worldwide in 2019”. Every year, more people die as a result of suicide than HIV, malaria or breast cancer   ̶  or war and homicide. In 2019, more than 700 000 people died by suicide: one in every 100 deaths, prompting WHO to produce new guidance to help countries improve suicide prevention and care.

“We cannot – and must not – ignore suicide,” said Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. “Each one is a tragedy. Our attention to suicide prevention is even more important now, after many months living with the COVID-19 pandemic, with many of the risk factors for suicide   ̶   job loss, financial stress and social isolation – still very much present. The new guidance that WHO is releasing today provides a clear path for stepping up suicide prevention efforts.”

Among young people aged 15-29, suicide was the fourth leading cause of death after road injury, tuberculosis and interpersonal violence.

Rates vary, between countries, regions, and between males and females.

More than twice as many males die due to suicide as females (12.6 per 100 000 males compared with 5.4 per 100 000 females). Suicide rates among men are generally higher in high-income countries (16.5 per 100 000). For females, the highest suicide rates are found in lower-middle-income countries (7.1 per 100 000).

Suicide rates in the WHO African (11.2 per 100 000), European (10.5 per 100 000) and South-East Asia (10.2 per 100 000) regions were higher than the global average (9.0 per 100 000) in 2019. The lowest suicide rate was in the Eastern Mediterranean region (6.4 per 100 000).

Globally, the suicide rate is decreasing; in the Americas it is going up

Suicide rates fell in the 20 years between 2000 and 2019, with the global rate decreasing by 36%, with decreases ranging from 17% in the Eastern Mediterranean Region to 47% in the European Region and 49% in the Western Pacific.

But in the Americas Region, rates increased by 17% in the same time period.

Although some countries have placed suicide prevention high on their agendas, too many countries remain uncommitted. Currently only 38 countries are known to have a national suicide prevention strategy. A significant acceleration in the reduction of suicides is needed to meet the SDG target of a one-third reduction in the global suicide rate by 2030.

To support countries in their efforts, WHO is today releasing comprehensive guidance for implementing its LIVE LIFE approach to suicide prevention. The four strategies of this approach are:

• limiting access to the means of suicide, such as highly hazardous pesticides and firearms;
• educating the media on responsible reporting of suicide;
• fostering socio-emotional life skills in adolescents; and
• early identification, assessment, management and follow-up of anyone affected by suicidal thoughts and behaviour.

Banning of the most dangerous pesticides: a high-impact intervention

Given that pesticide poisoning is estimated to cause 20% of all suicides, and national bans of acutely toxic, highly hazardous pesticides have shown to be cost-effective, such bans are recommended by WHO. Other measures include restricting access to firearms, reducing the size of medication packages, and installing barriers at jump sites.

Responsible reporting by the media

The guide highlights the role the media plays in relation to suicide. Media reports of suicide can lead to a rise in suicide due to imitation (or copycat suicides) – especially if the report is about a celebrity or describes the method of suicide.

The new guide advises monitoring of the reporting of suicide and suggests that media counteract reports of suicide with stories of successful recovery from mental health challenges or suicidal thoughts. It also recommends working with social media companies to increase their awareness and improve their protocols for identifying and removing harmful content.

Support for adolescents

Adolescence (10-19 years of age) is a critical period for acquiring socio-emotional skills, particularly since half of mental health conditions appear before 14 years of age. The LIVE LIFE guidance encourages actions including mental health promotion and anti-bullying programmes, links to support services and clear protocols for people working in schools and universities when suicide risk is identified.

Early identification and follow-up of people at risk

Early identification, assessment, management and follow-up applies to people who have attempted suicide or are perceived to be at risk. A previous suicide attempt is one of the most important risk factors for a future suicide.

Health-care workers should be trained in early identification, assessment, management and follow-up. Survivors’ groups of people bereaved by suicide can complement support provided by health services. Crisis services should also be available to provide immediate support to individuals in acute distress.

The new guidance, which includes examples of suicide prevention interventions that have been implemented across the world, in countries such as Australia, Ghana, Guyana, India, Iraq, the Republic of Korea, Sweden and the USA, can be used by anyone who is in interested in implementing suicide prevention activities, whether at national or local level, and in the governmental and nongovernmental sectors alike.

“While a comprehensive national suicide prevention strategy should be the ultimate goal for all governments,” said Dr Alexandra Fleischmann, suicide prevention expert at the World Health Organization, “starting suicide prevention with LIVE LIFE interventions can save lives and prevent the heartbreak that follows for those left behind.” 

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Communications Officer World Health Organization

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• Essay on Drugs

Cause Of Death Essay Examples

Type of paper: Essay

Topic: Drugs , Cocaine , Alcoholism , Alcohol , Liver , Cocaethylene , Substance , Body

Published: 03/08/2023

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The deceased died due to Cocaethylene toxicity. That is an overdose of the contents of cocaine and alcohol substance in the liver. The manifestation of a fenestration of the nasal septum in the victim’s body proves that she was a cocaine user. The cardiovascular abnormalities and damages plus the condition of lungs show the side effects of excessive cocaine intoxication since detoxification occurs in the liver (Cittadini et al., 2015). Usually, when an individual takes a significant amount of substance that is dangerous to the body, metabolism takes place so that they can be eliminated in the urine. Cocaine substance and alcohol are both toxic and are hazardous to the body in high contents. Hence, when in excess, they are sent to the liver for metabolic process. Cocaethylene is an exceptional chemical that occurs in the liver once an individual simultaneously consumes liquor and cocaine in excess. When these two substances meet inside the liver the metabolic dispensation of cocaine is interrupted by alcohol. Now the Cocaine (benzoylmethylecgonine) merges with alcohol (ethyl alcohol) to form ethylbenzoylecgonine (cocaethylene) (Dinis-Oliveira, 2015). At this time, ethyl alcohol disrupts cocaine dispensation of roughly about twenty percent. In turn, when the liver tries to remove cocaethylene alcohol the process is slowed down by about twenty percent. After about two hours, a significant amount of the element passes to the brain producing a much stronger effect than either of the first substances alone. Besides, according to Cittadini, et al. (2015), once the production of cocaethylene begins, the liver will emit the content for some hours. Evidently, it stays extensively in the body system at least three times than cocaine which is very dangerous because the substance is the major cause of heart damages in new cocaine users.

Cittadini, F., Giovanni, N., Alcalde, M., Partemi, S., Campuzano, O., Brugada, R., & Oliva, A. (2015). Genetic and toxicologic investigation of Sudden Cardiac Death in a patient with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) under cocaine and alcohol effects. International Journal Of Legal Medicine, 129(1), 89-96. doi:10.1007/s00414-014-1119-5 Dinis-Oliveira, R. J. (2015). Metabolomics of cocaine: implications in toxicity. Toxicology Mechanisms & Methods, 25(6), 494-500. doi:10.3109/15376516.2015.1072612

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Preprints with The Lancet is part of SSRN´s First Look, a place where journals identify content of interest prior to publication. Authors have opted in at submission to The Lancet family of journals to post their preprints on Preprints with The Lancet. The usual SSRN checks and a Lancet-specific check for appropriateness and transparency have been applied. Preprints available here are not Lancet publications or necessarily under review with a Lancet journal. These preprints are early stage research papers that have not been peer-reviewed. The findings should not be used for clinical or public health decision making and should not be presented to a lay audience without highlighting that they are preliminary and have not been peer-reviewed. For more information on this collaboration, see the comments published in The Lancet about the trial period, and our decision to make this a permanent offering, or visit The Lancet´s FAQ page, and for any feedback please contact [email protected] .

Cross-National Evidence on Risk of Death Associated with Loneliness: A Survival Analysis of 1-Year All-Cause Mortality Among Older Adult Home Care Recipients in Canada, Finland, and Aotearoa | New Zealand

23 Pages Posted: 13 Sep 2024

Bonaventure Amandi Egbujie

University of Waterloo

Gustavo Betini

Sandra ochwat, reem t. mulla.

University of Waterloo - School of Public Health Sciences

Finnish Institute of Health and Welfare

Johanna Edgren

Mari aaltonen.

Tampere University

Irihapeti Bullmore

The Nurse Maude Association

Cheung Gary

University of Auckland

Hamish A. Jamieson

University of Otago

Philip J. Schluter

University of Canterbury - School of Health Sciences

John P. Hirdes

Background: Loneliness is a growing public health problem that affects the health and well-being of older adults. It has been suggested to pose a risk of mortality similar to smoking. However, loneliness is understudied among vulnerable populations like home care recipients who experience higher rates of social disconnection. We examined the risk of mortality associated with loneliness for home care recipients after adjusting for potential confounders. Methods: We conducted survival analyses for population-based data of home care recipients in three countries: Canada, Finland, and Aotearoa | New Zealand (ANZ). Findings: A total of 178,610, 40,820 and 169,703 home care recipients in Canada, Finland and ANZ were included in the study, respectively. The respective baseline rates of loneliness in the three countries were 15·9%, 19·9% and 24·4% of recipients. In multivariate Cox regression analysis, being lonely independently predicted a lower likelihood of mortality among home care recipients with values of HR=0·82 (95% CI: 0·78-0·86) in Canada; HR=0·84 (95% CI: 0·79-0·89) in Finland; and HR=0·77 (95% CI: 0·74-0·81) in ANZ. Interpretation: Loneliness is pervasive in home-care settings across the three countries; however, its association with mortality differs from reports for the general population. Loneliness was not associated with an increased risk of death after adjusting for health-related covariates. The causal order between changes in health, loneliness, and mortality is unclear. For example, loneliness may be a consequence of those health changes rather than their cause. Future research should consider the temporality of loneliness with health conditions to better delineate its risk. Funding: This study received no specific funding. Declaration of Interest: The authors declare no conflicts of interest. Ethical Approval: Ethical approval for the study was obtained separately for each country. This included: University of Waterloo’s Office of Research Ethics (#30173) for Canada; the Institutional Ethical Review Board of the Finnish Institute for Health and Welfare for Finland (dnro THL/1118/6·02·00/2021); and the ANZ Ministry of Health and Disability Ethics Committee (14/STH/140/AM07) for ANZ.

Keywords: loneliness, mortality, home care, interRAI, aging, public health, cross-national

Suggested Citation: Suggested Citation

Bonaventure Amandi Egbujie (Contact Author)

University of waterloo ( email ), university of waterloo - school of public health sciences ( email ).

Waterloo, Ontario Canada

Finnish Institute of Health and Welfare ( email )

Tampere university ( email ).

Tampere, FIN-33101 Finland

The Nurse Maude Association ( email )

University of auckland ( email ), university of otago ( email ), university of canterbury - school of health sciences ( email ).

Ilam Road Christchurch 8140 New Zealand

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Facts About Suicide

• Suicide is a leading cause of death and affects people of all ages.
• Suicide is a serious public health problem and has far-reaching impact.
• Resources are available to prevent suicide.
• Hope is possible.

Leading cause of death

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Suicide is death caused by injuring oneself with the intent to die. A suicide attempt is when someone harms themselves with any intent to end their life, but they do not die as a result of their actions.

Many factors can increase the risk for suicide or protect against it. Suicide is connected to other forms of injury and violence. For example, people who have experienced violence, including child abuse, bullying, or sexual violence have a higher suicide risk. Being connected to family and community support and having easy access to healthcare can decrease suicidal thoughts and behaviors. 1

Serious public health problem

Suicide rates increased approximately 36% between 2000–2022. Suicide was responsible for 49,476 deaths in 2022, which is about one death every 11 minutes. 2 The number of people who think about or attempt suicide is even higher. In 2022, an estimated 13.2 million adults seriously thought about suicide, 3.8 million planned a suicide attempt, and 1.6 million attempted suicide. 3

Suicide affects people of all ages.

In 2022, suicide was among the top 9 leading causes of death for people ages 10-64. Suicide was the second leading cause of death for people ages 10-14 and 25-34. 2

Some groups have higher suicide rates than others.

Suicide rates vary by race/ethnicity, age, and other factors, such as where someone lives . By race/ethnicity, the groups with the highest rates are non-Hispanic American Indian/Alaska Native people followed by non-Hispanic White people. 2 Other Americans with higher-than-average rates of suicide are veterans, people who live in rural areas, and workers in certain industries and occupations like mining and construction. 1 4 Young people who identify as lesbian, gay, or bisexual have higher prevalence of suicidal thoughts and behavior compared to their peers who identify as heterosexual. 5 Read more about these suicide disparities and why they exist on the Health Disparities in Suicide webpage .

Far-reaching impact

Suicide and suicide attempts cause serious emotional, physical, and economic impacts. People who attempt suicide and survive may experience serious injuries that can have long-term effects on their health. They may also experience depression and other mental health concerns. 6

Suicide and suicide attempts affect the health and well-being of friends, loved ones, co-workers, and the community. When people die by suicide, their surviving family and friends may experience prolonged grief, shock, anger, guilt, symptoms of depression or anxiety, and even thoughts of suicide themselves. 6 7

The financial toll of suicide on society is also costly. In 2020, suicide and nonfatal self-harm cost the nation over $500 billion in medical costs, work loss costs, value of statistical life, and quality of life costs.

Suicidal behavior also has far-reaching impact.

There were 49,430 suicides among individuals ages 12 and older in 2022. But suicides are just the tip of the iceberg. For every suicide death*, there were about:

• 11 emergency department visits for self-harm**
• 52 self-reported suicide attempts in the past year*** 3
• 336 people who seriously considered suicide in the past year*** 3

*CDC National Center for Health Statistics (NCHS), National Vital Statistics System, Mortality 2018-2022 on CDC WONDER Online Database CDC WONDER ** CDC WISQARS (2022) *** Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on Drug Use and Health (NSDUH) https://www.samhsa.gov/data/report/2022-nsduh-detailed-tables

Suicide Prevention Resource for Action

Suicide is preventable. Everyone has a role to play to save lives and create healthy and strong individuals, families, and communities. Suicide prevention requires a comprehensive public health approach. CDC developed the Suicide Prevention Resource for Action (Prevention Resource), which provides information on the best available evidence for suicide prevention. States and communities can use the Prevention Resource to help make decisions about suicide prevention activities. Strategies range from those designed to support people at increased risk to a focus on the whole population, regardless of risk.

Strengthen economic supports

• Improve household financial security
• Stabilize housing

Create protective environments

• Reduce access to lethal means among persons at risk of suicide
• Create healthy organizational policies and culture
• Reduce substance use through community-based policies and practices

Improve access and delivery of suicide care

• Cover mental health conditions in health insurance policies
• Increase provider availability in underserved areas
• Provide rapid and remote access to help
• Create safer suicide care through systems change

Promote healthy connections

• Promote healthy peer norms
• Engage community members in shared activities

Teach coping and problem-solving skills

• Support social-emotional learning programs
• Teach parenting skills to improve family relationships
• Support resilience through education programs

Identify and support people at risk

• Train gatekeepers
• Respond to crises
• Plan for safety and follow-up after an attempt
• Provide therapeutic approaches

Lessen harms and prevent future risk

• Intervene after a suicide (postvention)
• Report and message about suicide safely

Need help? Know someone who does?

Contact the 988 Suicide and Crisis Lifeline if you are experiencing mental health-related distress or are worried about a loved one who may need crisis support.

• Call or text 988
• Chat at 988lifeline.org

Connect with a trained crisis counselor. 988 is confidential, free, and available 24/7/365.

Visit the 988 Suicide and Crisis Lifeline for more information at 988lifeline.org .

• Centers for Disease Control and Prevention. (2022). Suicide Prevention Resource for Action: A Compilation of the Best Available Evidence . Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
• National Vital Statistics System, Mortality 2018-2022 on CDC WONDER Online Database, released in 2024. Data are from the Multiple Cause of Death Files, 2018-2022, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10-expanded.html on April 23, 2024
• Substance Abuse and Mental Health Services Administration. (2023). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/reports/rpt42731/2022-nsduh-nnr.pdf
• Peterson C, Sussell A, Li J, Schumacher P, Yeoman K, Stone D. (2020) Suicide Rates by Industry and Occupation — National Violent Death Reporting System, 32 States, 2016. MMWR Morb Mortal Wkly Rep; 69: 57–62. DOI: http://dx.doi.org/10.15585/mmwr.mm6903a1 .
• Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Survey Data Summary and Trends Report: 2011-2021. Available at https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf [PDF – 10 MB] .
• Hamdan, S., Berkman, N., Lavi, N., Levy, S., Brent, D. (2020). The effect of sudden death bereavement on the risk for suicide. Crisis; 41(3):214–224. DOI: https://doi.org/10.1027/0227-5910/a000635 .
• Wagner, B., Hofmann, L., Grafiadeli, R. (2021). The relationship between guilt, depression, prolonged grief, and posttraumatic stress symptoms after suicide bereavement. J Clin Psychol; 77:2545–2558. DOI: https://doi.org/10.1002/jclp.23192 .

Suicide Prevention

Suicide is one of the leading causes of death in the United States. Learn more about Suicide Prevention.

For Everyone

Public health.